Does It Scale?

In today's hyper-charged startup environment, many businesses are focused on scaling-in other words, rapid growth while maintaining a particular standard of quality. The value of the business includes processes that will work at 10, 100, or even 1,000 times the current sales volume. The reason is simple: a company seeking to grow needs to jump-start its distribution in the market before incumbents can react to the new entrant. How to sustain such growth is an interesting question to ponder, and today's technology is helpful in answering it. Just as interesting are the techniques that startups use to achieve this. Small businesses like dental laboratories can benefit from asking the same question-"does it scale?"-that founders use when evaluating business processes.

Lean manufacturing is a bottom-up approach to answering this question. Issues that prevent a process from scaling by 100 include wasted time and materials, re-work due to an uncaught defect, or slow and unresponsive systems. A work step that takes 60 seconds must be considered very differently when it is done 100 times per day.

This article explores elements of today's digital dental laboratory that impact productivity and various ways to make them scale, from the general requirements for scalability that apply to many businesses to those more specific to scalability within a dental laboratory setting.

Networks

Internet Bandwidth

Consider the laboratory's digital receiving and shipping department, and estimate how much bandwidth it needs to be effective. Do technicians need access to video conferencing? How many files are typically transferred to and from clients and/or any outsource partners? Do team members use mobile devices for work communication? Verizon recommends 300 Mbps for 20 connected devices and uninterrupted video conferencing.¹ Zoom, an enterprise-level video conferencing company, recommends 2 Mbps per screen.²

One way to identify lack of adequate bandwidth is by discovering where the laboratory experiences delays in data exchanges. Regular interruptions and delays in service are signs that the laboratory's network may need to be upgraded.

There are Web-based tools available to help evaluate the performance of a business network.⁴For the most accurate measurement of what is being provided by an internet service provider (ISP), the laboratory can use one of these tools to test from a laptop connected directly via an ethernet cable to the ISP's equipment, with any networked applications on the laptop turned off. The laboratory owner should contact the ISP if the bandwidth received during this test does not match what the ISP was paid to deliver.

Wireless Connections

Wireless connections are convenient, but check the protocol your access point offers. You might not be using all of your bandwidth if your internal connections are not sufficient. 802.11ac is the latest protocol, which has a theoretical maximum of 1,300 Mbps. The next "youngest" protocol, 802.11n, reaches 450 Mbps. A, B, or G connections are no longer compatible with today's wireless devices.

Likewise, the number of access points on a network may hamper a laboratory's Wi-Fi availability. For most small offices, one access point is enough; however, there is a recommended number of devices that the access point allows. Partitions and walls may prevent the signal from reaching every user. Using the Wi-Fi signal strength detector of a smartphone can help people see where weak spots are and where to add additional access points, if necessary.

Wired Connections

Wired connections are predictable but not as flexible. Again, the connection equipment is critical. Is the switch or router rated for 10 Mbps or 100 Mbps? Nowadays, new equipment often comes with 1,000-Mbps (1-Gbps) Ethernet ports.

Network topology is an important factor in network transfer times. A router must be connected to the equipment provided by the ISP, or perhaps the ISP provides a router. These typically have four ports, but if more than four connections are needed, there are two options: a hub and a switch. Hubs echo all input to all connected devices (Figure 1). This tends to degrade the network's speed. In contrast, a switch will learn which device is making the network request and route the response back to that single device. The decrease in traffic increases the network's efficiency.

Monitors

Dental CAD programs require high-end graphics cards as part of computer monitor hardware. While these are now available in more laptops, such small screens are not practical for everyday business use-nor are they scalable. Having enough screen real estate powers productivity.⁶ Knowledge workers need to be able to synthesize information from various sources, so there should be enough screen space for all applications to be open and viewable at once. In order to view case data using laboratory management software, patient images, or any kind of dental CAD program, it is recommended to use at least two 20-inch monitors per workstation. However, using a single display of 30 inches or more is known to reduce neck strain.⁷

File Storage

On-premise storage is becoming a thing of the past. Cloud storage is fast, convenient, redundant, portable, and, most importantly, scalable. Amazon is one provider of storage services, offering Amazon S3. This service stores your file data on the same infrastructure Amazon uses to run its own business. While Amazon S3 is not very user friendly, the Amazon Storage Gateway makes things significantly easier for the layperson. With the addition of a local hardware device or cloud-based virtual machine, S3 can be mounted just like any other networked file system (Figure 2). Detailed instructions are provided for creating and configuring a Storage Gateway.⁸ Before implementing this strategy, however, laboratory decision makers should consider the costs of maintaining and upgrading a physical server versus paying  subscription fees.

It seems that as hard drives have bigger and bigger capacity, software applications find new ways to fill them up. Cloud storage is essentially off-premise storage, providing limitless space. While upgrading a hard drive is not hard to do, it can be very hard to schedule around production needs. Cloud storage enables scaling by removing the need to upgrade the physical infrastructure upon which your digital workflow depends.

Communication Services

There are now cloud-based options for hosted email, calendar, and cloud storage services. Microsoft offers hosted email, calendar, and One Drive^™ services, and Google Business Suite has a similar offering. These are priced per user per month,  so customers only pay for what they use. All of these services work with a business's custom domain.

In addition to communicating via telephone, email, or fax, there are now many platforms and tools for video conferencing. Screen sharing, in particular, can be helpful in the design approval process. Apple FaceTime, Google Hangouts, Microsoft Skype, WebEx, and Zoom are just a few conferencing options. Learning the main platforms used by their clientele should help a laboratory best determine which one is right for them.

Tracking customer interactions-especially in regard to how clients' concerns and cases are resolved-is important. Customer relationship management (CRM) is a burgeoning sector of the business software market. CRM software is available as an add-on to laboratory management software or as a standalone option. Collecting data about your customer interactions can lead to greater insight about your customer service experience.

A common bottleneck in the customer experience (CX) is when customer service team members become dedicated to a demanding customer. This is not scalable, as that particular customer's experience depends on the availability of one team member. One reason a customer may insist on direct access to a specific team member is that person's knowledge of the customer's ordering history. Using CRM tools to collect interaction data allows such information to be shared with the entire team. This does not remove the need of a CX lead for important customers. CRM tools allow inbound requests to be routed to the CX lead for each account. Information-sharing allows other team members to step in when the lead is not available. Search for patterns in the customer's experience to identify improvements and decrease the amount of time spent on customer service.

Digital Impressions

Simply accepting digital impressions at a laboratory does not mean they will move right into the workflow. Unless all digital impressions arrive in the same way and adhere to very clear specifications, time will be needed for processing. Currently, each digital impression system delivers the final scans in different ways. One way to streamline this is to develop a workstation that a single associate can use to transfer all digital impressions into the laboratory management system.

Once a manual process is in place, it should be evaluated and measured. Consider the steps it takes for the team to go from receiving an impression to designing the case, then identify which steps add value versus those that are repetitive and could be automated. Duplicate data entry is one example of such inefficiency. Strive to enter data only once into your master database or laboratory management system. Look for ways to automatically share with downstream workstations as needed. Traceability is not just a requirement the FDA places on medical device manufacturers; it is also valuable on its own as a tool to reduce errors and improve quality.

Manual processes become scalable when they can be described in a written document. A key characteristic of a scalable process is one that is repeatable. In other words, if a process cannot be described in such detail so that it is repeatable, then it will never scale. Once the process is repeatable, sources of error can be assessed, working time can be measured, and process automation can be considered.

Design

Design automation could be another path to scalability. Do the designers have access to the data they need to make design decisions? Are the design goals understood? Collecting and effectively communicating the dentist's design preferences are ways to automate the design process without the use of artificial intelligence. It is possible to capture 80% of a customer's design preferences so that a portion of the design work can be automated. While customer relationship management (CRM) is best known for its applications in marketing, it can also be applied to customer design preferences. CRM software is available as an add-on to laboratory management software or as a standalone option. Data collection, analysis, and visualization benefit all businesses and dental laboratories in particular. Look for tools that aid in handling the customer's data in a consistent way. In general, CRM is intended to provide the business's decision makers with a total picture of the customer. The goal is to have enough data about each client and patient from the records in the laboratory's CRM to automate a good portion of the design work.

Integration

As the dental CAD revolution continues, dental technology has an array of powerful software tools from which to choose. For the most part, dental laboratories do a good job of transferring files to their design and manufacturing partners. It is the dentist who might have the hardest time finding and sending files. Several major CAD software providers have their own case-sharing capabilities, and are all moving closer to the dentist. One software manufacturer boasts that its dental sharing platform "provides quick and reliable transfer of entire cases between dentists, laboratories, and production centers." However, a laboratory could enlist an integration specialist to connect its design software of choice with its preferred manufacturer in a seamless way. Evaluate the need for integration with the same tools used for a physical process. Investing in error-free transfer protocols pays off in more efficiently employing the team's time and labor, not to mention faster and more consistent turnaround times.

Integrated systems can make a process scalable. Time spent on pushing and pulling data with service providers is time not available for meeting the customer's other expectations. Short tasks, repeated many times, add up to a real time investment. An integration specialist can help identify the repetitive tasks that are needed to move an order through the multiple software systems that constitute a digital workflow. Integration schemes should be flexible enough to allow it to be adapted as upstream and downstream systems change.

Outsourcing

Whether for basic business processes or dental technology-specific services, laboratories of various sizes outsource some of their work. There are subscription services for accounts payable and even human resource functions. Outsource manufacturers of specific dental offerings can act as trusted partners, supplying products that do not fit the laboratory's existing portfolio. The capabilities afforded by outsourcing make it easier than ever for every dental laboratory to be full-service. This includes design as well as manufacturing. When asked about the role of outsourcing in today's environment, one digital manufacturer uses an analogy: "An outsource design or manufacturing center is like the specialist a patient is referred to by their general practitioner. The dental laboratory can rely on the specialized strengths of their outsource partner to provide high-quality restorations or devices they can't produce on their own." He continues, "Outsourcing provides scalability and flexibility when growing a new product area."

File Preparation for 3D Printing

Design files sometimes need to be pre-processed, or "fixed," as preparation for 3D printing.  Why is this needed? Depending on the way the design file is generated, there could exist holes or gaps in the mesh described by the design file. These gaps interfere with the algorithms used by the 3D printer's software to determine how to reproduce the geometry. Depending on all the variables of the design process, the need to repair meshes might have a high enough occurence that a dedicated file preparation step is needed. There are a number of options for software tools to address mesh repair. Mesh repair is accomplished by applying algorithms that will detect and close holes and mismatched edges. Some tools allow the user to further manipulate the design files via free-hand 3D geometry generation. MeshMixer from AutoCAD is free software that provides common mesh repair tools.¹¹ A number of videos on YouTube show how to clean meshes. One orthodontist is using it to design models for aligners.¹² Define a work instruction or procedure for this process step. Train to the procedure. Determine what adds value and what does not. Look for tools to automate the steps that do not add value.

MeshLab is another free software that includes a "headless" server, plugin architecture, and macro language.¹³ While not as user friendly as MeshMixer, it makes automating a data processing pipeline possible. Once a data processing pipeline is developed, it can be deployed and accessed from the cloud. Cloud functions eliminate the need to maintain a desktop in the production environment.

Preventive Maintenance

To avoid interrupting the manufacturing process mid-stream, laboratories should keep their tools in good working order. Follow the manufacturer's recommendations to ensure that maintenance is performed as prescribed. Keeping a log book-whether on paper or in a computer document-is a simple and effective way of managing preventive maintenance. Include the instructions in the log book along with a sample entry format that specifies all the information that needs to be collected; this will make it easier for any team member to participate in this maintenance. Using an online spreadsheet or dedicated software for this purpose is another option. The right method is whichever technology maximizes regular upkeep.

Preventive maintenance plans support scalability by ensuring that capacity planning is as accurate as possible. Capacity planning is how the team determines how to enable  sales growth. Planned downtime for maintenance is the best insurance that each workstation is available for as many hours as the operations team needs it.

Case Delivery

Just as wasteful aspects in design and manufacturing processes can be reduced or eliminated, so can inefficiencies in the shipping protocols. Laboratories should scrutinize this process in the same way they looked for waste in the "value creation" steps. For higher-volume customers, it may be possible to consolidate case shipments, which would result in reduced costs and labor.

Processes for packaging completed cases must have strict compliance, especially for ensuring that all steps have been completed. Visual inspection is highly suspect, with many studies observing inspection error rates of 20% or more.¹⁴ Therefore, it is a good idea to use a management system module to help streamline and standardize packaging and inspection protocols.

FedEx, UPS, and the U.S. Postal Service all have support for software and hardware vendors. Laboratories should check their laboratory management software for integrated support of their preferred carrier(s); asking associates to switch between vendor platforms can easily lead to mixups. Consider, for example, how many clicks it takes to schedule a case for shipment or even just to print the shipping label. Is it possible to initiate the print from a code scan of the case traveler? After the label is printed, the carrier's tracking information should be added to the case record and communicated to the customer. Follow the steps necessary to get the package out the door and your customer service team ready to answer the customer if they call to ask about a shipment's location.

Conclusion

In order to grow, each business must consider what it can do now to prepare for scaling up. This absolutely applies to laboratories. They can certainly make use of the latest iteration in networking and computing technology, utilizing subscription-based software and services that allow for expansion. Technological advancements for design and manufacturing should free up time for a business to focus on the customer, not the machines, paving the way for making the laboratory more profitable. Outsourcing options, too, offer laboratories a wider array of product offerings and the flexibility to ramp up those resources as needed.

Dental laboratories cannot afford to waste time and effort doing repetitive tasks that do not add value; waste is an impediment to scaling. The first step in getting rid of waste is to know where it is, so engage your team doing the work to find the waste and eradicate it. It might not be hard to fix, or maybe the hardest part is just scheduling the time to fix it. Strive for business processes that work the same way every time-at any scale.

About the Author

Terry Lorber, MSc
Principal
Meta Tooth LLC
Swampscott, MA

References

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